Name Change Notification

Request a Name Change

A licensee shall notify the board of any name and/or address change within 30 days of the change. Please keep in mind this is public information. Please complete the form below and we will update your record. IF you ONLY need to change your address, please access the online services page located athttps://IBPLicense.iowa.gov/ to change your address.

If you would like to receive a new licensure card and/or license certificate due to the name change, you must pay the $20.00 fee. This can be done by accessing the online services page located athttps://IBPLicense.iowa.gov/

Establishments can change the name of their establishment ONLY as long as the ownership has not changed. If an establishment has an ownership and/or address change a new license application is required. This can be done by accessing the online services page located at https://IBPLicense.iowa.gov/

Fields marked with an * are required.

Board:

* Profession:

* License Number:

* First Name:

Changed?

Middle Name:

Changed?

* Last Name:

Changed?

Suffix:

* Date of birth:

Month:Day:Year:

* Mailing address line 1:

Changed?

Mailing address line 2:

Changed?

* City:

Changed?

* State:

Changed?

* ZIP code:

Changed?

Daytime phone number:

Area code:Number: Changed?

Email:

Changed?

Confirm Email:

You may add a message for the Bureau of Professional Licensure in the text area below. No more than 1,000 characters may be sent in the message.